Study finds no significant drop in prescriptions to care home patients in the four years following the government's 2009 National Dementia Strategy

The authors of a study into how antipsychotic drugs are given to dementia patients in UK care homes have called for “significant changes in culture” to how prescriptions are managed and monitored.

The research paper found no sustained reduction in antipsychotic prescriptions – used to regulate behavioural and psychological symptoms and also known as the ‘chemical cosh’ – to such patients in the four years following the government’s 2009 National Dementia Strategy (NDS). A report commissioned that year by the Department of Health as part of the NDS recommended a review of their use, because of potential serious side effects – including death.

“The question here is is whether the Prime Minister’s Challenge will have an effect [given the NDS’s apparent lack of impact]”, lead author Professor Ala Szczepura, from Coventry University’s Centre for Technology Enabled Health Research, told Community Care. “There’s an opportunity here to think about the care home sector and how it can be supported.”

The report describes inappropriate antipsychotic prescription as a “marker of poor care”, and contrasts well-developed protections against physical restraint and deprivation of liberty with far sketchier ones when it comes to ‘chemical restraint’. As well as noting the overall persistence of antipsychotic drugs, it finds:

That older, less safe drugs are still being used extensively, rather than second-generation medications recommended by the NDS

That ‘excessive’ periods of prescription (lasting more than 12 weeks) rose from 69.7% of treatment courses in 2009 to 77% in 2012

That care homes in the highest-prescribing 20% were more likely to be in deprived areas

That care homes in the lowest-prescribing 20% were more likely to be served by a single GP.

Szczepura said that the findings indicate first of all how important it is that data continues to be gathered from the sector via new technology.

“There also needs to be a discussion about how to support care workers and clinical staff with training,” she said. “Some patients’ behaviour may be to do with pain they can’t articulate, not dementia, so can be treated with an analgesic instead.”

Szczepura added that the frequent practice of patients staying with their individual GPs, rather than identifying one surgery to look after a care home, makes implementing a consistent prescribing policy across homes very difficult and should be looked at.

George McNamara, head of policy at Alzheimer’s Society, described the continued use of antipsychotics to manage behavioural symptoms of dementia as “deeply worrying”.

“Antipsychotics increase the risk of stroke, falls and even death,” he said. “With person-centred approaches and training programmes for care home staff, continued inappropriate prescribing is a step backward into the dark ages.”

A spokesperson for the Department of Health said: “Reducing the use of antipsychotic drugs is a key commitment from the Challenge on Dementia 2020, and we are clear these drugs should not be used as a first resort.

“We are taking continued action to reduce inappropriate prescribing by making sure staff are trained to recognise and manage challenging behaviour in dementia patients. NHS England is also tackling the issue by recruiting specialist mental health pharmacists, and monitoring progress against our commitment to deliver a 67% reduction in antipsychotics by March 2019.”

A common condition of DoLS authorisation is for care homes to request regular reviews of this medication… But if you can’t change the culture amongst health professional there is little else you can do.

Many people, no matter what the age, are able to metabolise psychiatric drugs effectively. Research depicts antidepressants are linked with certain genetic variants which result in worsening behaviour such as akathisia, aggression, hallucinations, psychosis and suicideation.

Antipsychotics are metabolised through similar pathways to antidepressants and like wise can induce worsening behaviour. Because of lack of pharmacogenetic knowledge in the medical profession, the standard practice is therefore to increase the dose or add another antipsychotic which in turn increases patient distress.

There is another way to manage behaviour without resorting to toxic drugs

Proutys Pre Therapy is a technique used with dementia and other patient groups. And that is also so little known about in the UK

I think the chemical cosh label is overdone. First let’s stop demonizing care homes – doctors prescribe drugs, not homes. If a doctor feel a drug is not appropriate they should not prescribe it. Second let’s remember dementia is often a cruel set of conditions that causes mental suffering that is not always resolved by a kind word or a music session. In the later stages some people are driven to wander until they literally drop, or are seized by anxiety that cannot be addressed except by medication. If it were physical pain we would expect painkillers to be offered.
I dont know why the softer drugs like lorazepam are not tried sometimes before haloperidol. My gut feeling is that a little something to take the edge off anxiety would often work. Any medication should be reviewed and it’s my guess this often does not happen due to pressure on gp services. I remember working in a residential home with an old lady who has been discharged from one of the large old mental hospitals . She was virtually immobile and staff were getting impatient. I was shocked to see she was on a huge side of chlorpromazine. The manager said “oh no she has to stay on that”. I phoned the gp and he was clearly shocked too. “Just stop it” he said and put the phone down quickly. In days her mobility improved and there were no negative consequences.

I’m more concerned as to why 90 year olds with a short time to live are dosed with aspirin, statins etc or why those with advanced dementia are kept on anti dementia drugs which are clearly doing nothing except giving side effects.

as I could have guessed, the dols/bia process has had no discernible effect on the overuse of these drugs. being chemically sedated is a far more significant restriction of liberty for residents of care homes than being unable to leave without supervision. But hey ho, let`s fill in those form 3s til the cows come home…………

It’s interesting to see this article, because at present there is a TV series being aired in which a GP seeks to demonstrate that patients can be treated without constant recourse to medication. I’m fascinated to see what the outcome of this will be, because I suspect that in this country we have become far too reliant upon medication, pills and potions as a cure-all for a ludicrous number of ailments, some of which might be better addressed via other means. In accepting our over-reliance upon medication, we fail to explore the potential, and to reap the benefits, of alternative treatments (and by this I do not simply mean “alternative therapies ” in the sense of things like herbal medicine). It strikes me that there are a huge range of treatments out there for people which do not have to include the taking of medication. These range from physiotherapy, heat treatments, acupuncture, exercise, light therapy…

As Bill Nightingale correctly points out, many services have a long history of using such things as antipsychotics, sedatives and antidepressants to manage behaviour in patients and service-users. It is clear that increased and more intensive research is now necessary in order to explore the reasons why this happens. Perhaps we are dealing with a lasting legacy of our historic use of “lunatic asylums”? Historically, things like mental illness and learning disability have been stigmatized in such a way that those people whom society calls “normal” are able – even encouraged – to single out others who are viewed as “abnormal” (e.g. mentally unwell, or learning disabled) for less favourable treatment. In the past, such people might find themselves segregated and placed in “lunatic asylums”. This attitude and stigmatization has had lasting repercussions, and to this day, some people still view individuals who are mentally ill, learning disabled, or who display other “challenging” behaviours as “abnormal” and deserving of negative treatment.

Personally, I feel that excessive use of antipsychotic drugs – also of antidepressants, and sedatives – is symptomatic of a lasting negative societal attitude towards mentally ill, learning disabled and otherwise “different” people. I have personally met many people – including some healthcare practitioners (one of whom was my own manager at work, and also a qualified Nurse) – who are prejudicial in their attitudes towards people who appear “different”, particularly where that arises as a result of mental illness or similar. I was bullied mercilessly at school and at work because I have a parent who has mental health issues. If this can happen, in this day and age, it makes sense to see that it may lead to negative attitudes towards people who have things like dementia, and to excessive use of medication to “control” them.

Still, I don’t believe that prejudice is the ONLY factor involved. It interests me to note that the report highlights a higher incidence of inappropriate antipsychotic prescribing in DEPRIVED areas. This suggests that there are many factors at play, here, that may lead to such inappropriate use. The fact that this is occurring in care homes in deprived areas, may indicate that such care homes are inadequately and inappropriately staffed, and that they try to compensate for short-staffing, or for having poorly-qualified staff by chemically controlling residents. Had these homes been able to employ more staff, or better trained staff, then they might be able to spend more 1-1 time with residents, and they might have been better able to spend time monitoring and managing issues that could contribute to residents’ “challenging” behaviour. My feeling is that a range of things may be responsible for “challenging” behaviour amongst individuals who have dementia. Sometimes, it MAY be a symptoms of their dementia. However, it could just as easily be a sign of agitation caused by an untreated infection – such as a urinary infection, or a chest infection (changes in behaviour, and especially signs of agitation and confusion, can be symptomatic of respiratory or urinary infection in elderly people). It may be that a person with dementia finds it hard to articulate issues, and therefore cannot directly tell someone they are in pain, or feel ill. They may instead try to communicate a sense of this via “acting out” and what is perceived as “challenging” behaviour. Care homes that are short-staffed, or which do not employ very well qualified staff, may fins that their employees do not pick up on such issues.

Ironically, some residents of care homes may actually exhibit “challenging” behaviour that leads to their being prescribed antipsychotics, antidepressants or sedatives BECAUSE they HAVE been prescribed these things. Perhaps I am not explaining this well… What I mean is that some medications have side-effects, which may in some people present as “challenging” behaviours, or which may be misinterpreted as such. Yvonne Bonifas gives a good example of this by describing an elderly lady who presented as very slow moving, and almost immobile – much to the frustration of staff. The irony is that although staff of the care home where this lady resided seemed to believe that she needed the medication she was on, it was the actual medication that was causing the presentation (immobility) that most annoyed them! We should all try to make ourselves aware of the side-effects of medication that people we work with are taking. In some cases, these side-effects can include forgetfulness, slurred speech, “hangover”-type presentation, lethargy, agitation, confusion… Isn’t it rather ironic that some of these medication side-effects can also be interpreted as both symptoms of dementia (and many other mental illnesses), as symptoms of learning disability, or as suggestive of “challenging” behaviour? It strikes me as somewhat ridiculous that medications may be prescribed to control such things as dementia, or maybe anxiety, or depression, or ADD … but which may produce side-effects that are pretty similar to symptoms they are supposed to control!

We should further be aware that people who take medication for protracted periods can become both psychologically and/or physically addicted to it, AND they can also build up a tolerance to medication that means its dose must be continually increased. These situations are both problematic. The addicted person becomes dependent on medication, meaning that it is very difficult to wean them off it. Sometimes, people can become dependent, though the medication actually has little to no real benefit, and has many debilitating side-effects. People who have become tolerant of a given medication tend to see no further benefits at the original dosage level, which often leads to medics increasing dose. The problem with this is that the person taking the medication gets trapped in a cycle of increasing doses of medication, punctuated by plateaus where they see no further benefit until the dose is increased again. As a consequence, such individuals end up taking doses of medication which are at the limit of what are considered safe. In these cases, too, it can be hard to then wean these people off their medication – usually because they have been taking it for so long and at such high doses. Sometimes they may additionally have become addicted.

Even weaning a person off medication is fraught with problems, because lessening a dose may mean that a person begins to see “breakthrough” symptoms (i.e. symptoms that were not evident when the person took a high dose of medication may show up when it is lowered). Sadly, some patients may fear such “breakthrough” symptoms – as may their carers, family and friends. Indeed, some medical professionals may also fear or resent “breakthrough” symptoms. This may see such symptoms misinterpreted as a “relapse” or as the “illness getting worse”. This is not so, rather, such symptoms are part and parcel of coming off a medication because once the medication is no longer masking symptoms, they are evident once more. As opposed to fear of “breakthough” symptoms, people should be taught to recognize that they are part of their illness, and that their presence is merely a sign that the medication is now out of the person’s system. This should act as a prompt to seek other ways to manage symptoms without medication. It can actually be a liberating experience if viewed correctly, as the individual now has choices of their own to make about how best to manage symptoms.

I do feel that teaching staff how to identify and manage “challenging” behaviour in dementia patients may be a valuable resource that leads to improvements in care. I also feel that there may indeed be value in training and employing specialist mental health pharmacists. It is also a good idea to advise that drugs such as antipsychotics should not be used as a first resort. Rather, staff should be exploring with patients the different treatment options.

There should be different ways of giving patients what they need. Chemical cosh is the horrible way of “shutting them up”. I live with one resident who tells me that he’s all there. I believe him. His opinions are far wiser than the care home staff. We flirt with each other when the care home staff aren’t in the same room. Care homes can try to deprive us of liberty as much as they like, but we will still have the right to do what we please, because us care home residents will do it behind the staff’s backs.We’re not draconian or rigid. No matter what care home staff think. We will make love with each other regardless. Who is ANYONE to take that basic human right from us?

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